Casting Out Complications: Total Contact Casting Vs External Fixators For Flap Off-Loading

Document Type

Book Review

Publication Date

9-2026

Publication Title

Plastic and Reconstructive Surgery. Global Open

Abstract

Objective: Postoperative management of lower extremity free flaps is complicated by dependent edema, risk of dehiscence with early weight-bearing, and prolonged immobilization. External fixation is commonly used for offloading but carries significant morbidity, including high rates of pin tract infection and limitations in compression therapy. We evaluate a protocol combining multilayer compression wrapping with total contact casting (TCC) as an alternative strategy for flap protection and offloading. Methods: A retrospective review was performed of 93 patients undergoing lower extremity free flap reconstruction between 2018 and 2023. Patients were managed with either external fixation (Ex-Fix, n=13) or a standardized protocol of multilayer compression wrapping beneath total contact casting (TCC, n=80). The TCC protocol was initiated on postoperative day 5 following initial splinting and strict elevation, with no use of dangling. Compression layers (Webril, Ace, and Coban) were applied beneath the cast to control edema. Selected patients were allowed limited protected ambulation in a cast shoe. Outcomes included flap viability, wound complications, and donor site morbidity. Results: Flap survival was comparable between groups (ExFix 92.3% vs TCC 93.8%). However, complication rates were significantly higher in the Ex-Fix cohort. Pin tract infections occurred in 23.1% of Ex-Fix patients and in none of the TCC group (P =.002). Wound dehiscence was more frequent in Ex-Fix patients (46.2% vs 8.8%, P =.002), as was flap edema (30.8% vs 8.8%, P =.044) and hematoma formation (23.1% vs 3.8%, P =.032). Donor site complications were rare and similar between groups. In high-risk patients with diabetes or peripheral vascular disease, complication rates remained consistently higher in the Ex-Fix group. Conclusion: Multilayer compression wrapping combined with total contact casting provides effective flap protection and offloading while significantly reducing complications compared to external fixation. This technique eliminates pin-related morbidity, enables controlled early ambulation, and facilitates edema management through integrated compression. It represents a simpler, lower-risk alternative to external fixation in lower extremity free flap reconstruction.

Volume

14

Issue

S4

First Page

14

Last Page

14

Comments

Michigan Academy of Plastic Surgeons Annual Meeting, July 12-15, 2026, Mackinac Island, MI

DOI

10.1097/01.GOX.0001276740.20920.55

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